Off-label use of interwoven carotid stent in common femoral artery occlusion after surgery

Abstract

Open surgery is the gold standard for treating common and deep femoral arterial lesions. Nevertheless, significant data have emerged in recent years supporting an endovascular strategy for this peculiar anatomic region, despite certain disadvantages, including the requirement for strong compression resistance and excellent flexibility and conformability when stents are implanted. We present a case of critical limb ischemia due to total common and deep femoral arteries occlusion after endarterectomy that resulted in a very tapered lesion. It was successfully treated with percutaneous angioplasty and off-label application of an interwoven nitinol Roadsaver carotid artery stent, which demonstrated good adaptability.

Keywords: Carotid stent; Chronic limb-threatening ischemia; Common femoral artery; Endovascular; Off-label use.

Fig 1

A, Preoperative digital subtraction angiogram showing total occlusion of the right common femoral artery (CFA) and first third of the deep femoral artery (DFA). The external iliac artery is not visible in this frame but was patent until almost the origin of the epigastric artery. B, The superficial femoral artery (SFA) was occluded during previous endarterectomy (EA) and was supplied in the middle to distal third by collateral vessels. Runoff to the leg was maintained by the distal SFA (supplied by collateral vessels from the DFA), popliteal artery, and anterior tibial artery.

Fig 2

A, The lesion length appeared to be ∼36 mm after crossing the occlusion, shorter than previously estimated. Crossing was obtained by combined maneuvers with a diagnostic 5F catheter (MPA; Cordis Corp), a supportive 2.6F microcatheter (CXI; Cook Medical Inc), and a 0.018-in. guidewire (V18; Boston Scientific). B, After multiple dilatations with plain old balloon angioplasty and drug-eluting balloons, a short dissection was noted at the distal part of the common femoral artery (CFA; white arrow). The image was taken at hip flexion of ∼45° and revealed no bending of the deep femoral artery (DFA).

Fig 3

Completion digital subtraction angiogram demonstrating complete recanalization of the common femoral artery (CFA) and deep femoral artery (DFA) and good patency of the distal DFA and its branches.

Fig 4

A, Detail of completion digital subtraction angiography focusing on the Roadsaver stent after deployment and postdilatation on the deep femoral artery (DFA). The stent adapted correctly to the lesion, with good apposition in both the common femoral artery (CFA) and the DFA, despite the large difference in diameters between the two arteries. B, The interwoven nitinol design permits superior adaptability to the tapered morphology of the lesion, with maintenance of the correct structure of the entire stent. The angles between the wires are not very dissimilar in the DFA (stent elongated) vs in the CFA (stent at nominal diameter), which are crucial for maintaining good flexibility of the device.

Fig 5

At 6 months after intervention, color Doppler ultrasound scans demonstrating regular stent patency (white arrow) in common femoral artery (CFA; A) and deep femoral artery (DFA; B), with no signs of stent fracture or intraluminal hyperplasia. The peak systolic velocity flow within the stent was ∼100 cm/s (C).